AccountId: 011433970860
ContactId: d94681a7-6e85-44ad-85e9-34c1f141c39c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 753700 ms
Total Talk Time (AGENT): 222756 ms
Total Talk Time (CUSTOMER): 252500 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/25/d94681a7-6e85-44ad-85e9-34c1f141c39c_20250625T13:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Awesome
[CUSTOMER][NEUTRAL] Hi Ms. [PII], my name is [PII].
[AGENT][NEUTRAL] So, how can I help?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Uh yes ma'am. I was calling to see if you can help me with a benefit breakdown for a patient.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yeah, absolutely. Happy to check benefits. Do we have a policy number for the patient?
[CUSTOMER][NEUTRAL] Uh, she gave me 0262545.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And that was 0262545?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Alright, I think we might be missing.
[AGENT][NEUTRAL] Number let's see.
[AGENT][NEUTRAL] OK, yeah, that didn't come up. Do you have their name? We can check by that?
[CUSTOMER][NEUTRAL] Yeah, um, first name is [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Last name is [PII]
[CUSTOMER][POSITIVE] And I can also give you the the social if that helps.
[AGENT][NEUTRAL] All right. Are we looking for medical or dental?
[CUSTOMER][NEUTRAL] Dental.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then what is the patient's date of birth?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] OK. So it looks like you're just missing a one. It's um 02612545.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So there's a 1 in between 6 and 2.
[AGENT][NEUTRAL] Mhm. Yup. And she is active. Effective date on here is [PII]. Um, I can give you a verbal breakdown or send you a fax back, whatever works best.
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] There's a few questions I do have um that I know they're not gonna be on the insurance fax back but if I can have a fax back too that'd be great.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yeah, no, absolutely. What do you, what kind of questions did you have?
[CUSTOMER][NEUTRAL] Um, do you know if we are in network or out of network?
[CUSTOMER][NEUTRAL] With your plan?
[AGENT][NEUTRAL] So the patient's plan participates in the Carrington PPO network. Um, however, it's not required to use. Otherwise it just pays off of UCR.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You see, OK.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Any fee schedule that is used for this?
[AGENT][NEUTRAL] No, no fees, just UCR.
[CUSTOMER][NEUTRAL] Just the UCR?
[CUSTOMER][NEUTRAL] OK doke and when is the benefit renewal for the plan?
[AGENT][NEUTRAL] Um, it's a calendar year plan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, is there any waiting periods for the plan?
[AGENT][NEUTRAL] Uh, no, there is not. The patient only, the patient has preventative and basic, so there's no waiting period on the plan.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the deductible applies to either preventative or basic?
[AGENT][NEUTRAL] Uh, deductible does apply to basic, not preventative.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so just to confirm you did say that this plan only covers preventative and basic.
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] OK um.
[CUSTOMER][NEUTRAL] For the limited exam 0140.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Would that be under?
[CUSTOMER][NEUTRAL] Preventative
[AGENT][NEUTRAL] Uh, yes, actually I don't show, so we have 0150 listed here, don't show 00140.
[CUSTOMER][POSITIVE] Thank you
[AGENT][NEUTRAL] Oh yes, it is actually 0140 is under basic at 80. I apologize.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there any frequencies for that code?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] It is limited to 2 oral evaluation procedures in a 12 month period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, does the share frequency with anything else like uh a 0150?
[AGENT][NEUTRAL] Uh, yes, it shares frequency with, yeah, 0150, 0160, and 0120.
[CUSTOMER][NEUTRAL] Or
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And can we do same day treatment or is it for accidental only?
[AGENT][POSITIVE] Yeah, you can do same day.
[CUSTOMER][NEUTRAL] OK, does it cover accidental?
[CUSTOMER][NEUTRAL] Only no, right?
[AGENT][NEUTRAL] Mm. No, I don't know.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And for the code 9310.
[CUSTOMER][NEUTRAL] Is that a cover benefit?
[AGENT][NEUTRAL] Let's see, 9310.
[AGENT][NEUTRAL] Uh yes, it looks like that is covered at 80% with no limitation.
[CUSTOMER][NEUTRAL] OK, and does it share any frequency?
[AGENT][NEGATIVE] No, it does not.
[CUSTOMER][NEUTRAL] OK, is same day treatment allowed or?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, can we take X-rays, um, or is it X-rays only?
[AGENT][NEUTRAL] Uh, yeah, there are X-rays. Mhm.
[CUSTOMER][NEUTRAL] OK, is it limited to a specialist?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, the other code I have is palliative treatment 9110.
[AGENT][NEUTRAL] So it looks like that is covered at basic at 80%. I'm not showing any limitation or frequencies.
[CUSTOMER][NEUTRAL] OK, same day treatment as well on that?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, I completely forgot to ask, is there a messages who call on this plan?
[AGENT][NEUTRAL] Oh, let's see. It does have a missing tooth clause, yes.
[CUSTOMER][NEUTRAL] OK, and does preventative diagnostic, is it, does it pull from the maximum?
[AGENT][NEUTRAL] Uh, yes, it would. Uh-huh.
[CUSTOMER][NEUTRAL] OK, and do we need to file medical first for surgery?
[AGENT][NEGATIVE] Uh, yeah, you would, yeah, because there is no surgery benefit on here, so it wouldn't be covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Is there anything on this plan that requires mandatory um preauthorization?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Alright, and do you know how many PAs are needed for the day for it to be considered or equal to a FMX?
[AGENT][NEUTRAL] Uh, no, let's see.
[CUSTOMER][NEUTRAL] In
[CUSTOMER][NEUTRAL] I know typically sometimes it's either 12 or 14, sometimes 16.
[AGENT][NEUTRAL] I don't show that. Yeah, I'm not I'm not certain.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And it was how many FMX are required for, I apologize.
[CUSTOMER][NEUTRAL] Oh no, no, um, how many PAs are needed for it to equal SMX?
[AGENT][NEUTRAL] Let me, yeah, let me see.
[AGENT][NEUTRAL] Yeah, it looks like it's 14.
[CUSTOMER][NEUTRAL] 14, OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Typically, um, I'm just asking questions that I know for sure are not gonna be on the breakdown um for the ceiling guidelines is does that cover molars, premolars, or primary?
[AGENT][NEUTRAL] Let's see first see it.
[AGENT][NEUTRAL] It looks like it's for applications to permanent molar teeth only.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, now I have my question for restorative. Do you know if restorative composites downgraded to amalgam?
[AGENT][NEUTRAL] I know there's no downgrade on it.
[CUSTOMER][NEUTRAL] And let me see.
[CUSTOMER][NEUTRAL] 4381.
[CUSTOMER][NEUTRAL] For antimicrobial agent.
[CUSTOMER][NEUTRAL] Would that be a cover benefit?
[AGENT][NEUTRAL] Uh, 4381 isn't listed on the fax back, so it's not covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] And 4346.
[AGENT][NEGATIVE] Not listed.
[CUSTOMER][NEUTRAL] 4341.
[AGENT][NEUTRAL] 4341.
[AGENT][NEUTRAL] Is not listed either.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 4910.
[AGENT][NEUTRAL] No, 4910 either.
[CUSTOMER][NEUTRAL] 4260.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] No, 4260.
[CUSTOMER][NEUTRAL] I guess my question now would be would endo perio and oral surgery be considered as major restorative?
[AGENT][NEUTRAL] Yeah, those are all considered major.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, doke, that way we can skip over that and then just restorative, yeah, I don't know why you didn't think of that earlier restorative if you did say 80, correct?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, doke, I think that's it and is this this patient have any history on the plan?
[AGENT][NEUTRAL] Uh, let's take a look.
[CUSTOMER][NEUTRAL] Yeah,
[AGENT][NEUTRAL] No, no history on file, and then if you want to just give me a fax, I can send you over the fax back.
[CUSTOMER][NEUTRAL] Yeah, that'd be great, um, it's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Should we mark attention to anybody?
[CUSTOMER][NEUTRAL] No ma'am.
[AGENT][POSITIVE] OK. Uh, give it about 5 minutes and you should have that. Anything else I can check on for you?
[CUSTOMER][POSITIVE] No, I think you cover it all thank you so much.
[AGENT][POSITIVE] You're welcome. Have a good day.
[CUSTOMER][POSITIVE] Thank you too bye.
[AGENT][NEUTRAL] Mm bye-bye.